Int.J.Curr.Microbiol.App.Sci (2014) 3(12): 845-849
ISSN: 2319-7706 Volume 3 Number 12 (2014) pp. 845-849
http://www.ijcmas.com
Case Study
Coital laceration resulting in recto-vaginal fistula: A case report
H.M.Abdullahi and IA..Yakasai*
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital Kano,
PMB 3452 Kano, Nigeria
*Corresponding author
ABSTRACT
Keywords
Coital
laceration,
rectovaginal
fistula
Although coitus is quiet pleasurable, it may sometimes be risky especially in
nulliparous woman with little or no foreplay. Most cases of RVF are caused by
obstetric injuries, surgical complications, infections and may follow normal
consensual coital acts. In present case of coital injury that resulted in rectovaginal
fistula in a twenty four year old woman. She sustained the injury following her first
sexual relationship. She noticed that she was passing watery stool through the
vagina five days after the intercourse. She reported to two general and several
private hospitals were she was reassured. The problem of leakage of faeces per
vagina persisted for over four years and only sought for further help when the
husband noticed a formed stool on his genital following intercourse. She was
managed successfully. Prompt intervention and thorough examination of the
woman is required when clinicians are faced with coital injuries to exclude
rectovaginal fistulae.
Introduction
Failure to recognize and correctly repair
perineal lacerations, or secondary infection
of perineal lacerations, further increases the
chance of RVF. Prolonged labor with
pressure on the rectovaginal septum can
produce necrosis and result in RVF.
Traumatic injury (penetrating or blunt) and
forceful coitus also have resulted in RVF
(Omo-Aghoja et al., 2009). Although trauma
at sexual intercourse remains an everyday
occurrence, most are minor and manifest as
self-limiting injuries with minimal vaginal
bleeding,
requiring
no
medical
attention(Omo-Aghoja et al., 2009).
Rectovaginal
fistulas
are
abnormal
epithelial-lined connections between the
rectum and vagina (Teresa and Jaime, 2010).
They can be quite worrying to both the
patient and the surgeon due to their irritating
and embarrassing symptoms (Onsrud et al.,
2008). There are several causes of
rectovaginal fistula (RVF) (Teresa and Jaime,
2010).
Perineal lacerations during childbirth,
especially those due to episiotomy,
predispose patients to RVFs. Perineal
lacerations
are
more
common
in
primigravidas and precipitous births, or
following instrumental vaginal deliveries.
Nulliparity, low levels of education, non845
Int.J.Curr.Microbiol.App.Sci (2014) 3(12): 845-849
consensual and premarital sex with little or
no foreplay were strongly correlated with
the risk of coital trauma (Sally et al., 2001).
Women with significant coital injuries may
present late. This delay may be due to fear
of stigmatisation or spousal rejection.
results of full blood count electrolytes and
urea were normal. A diagnosis of low/small
size (<0.5cm in diameter) recto vaginal
fistula was made. She was counseled and
consented for repair.
She was placed on low residue diet and oral
neomycin 500 mg 6 hourly for five days.
She was operated under spinal Anaesthesia.
She had transvaginal repair in which the
vaginal mucosa was circumferentially
elevated, exposing the fistula. Two
concentric purse string sutures were used to
invert the fistula into the rectal lumen using
vicryl suture no 2/0. The vaginal mucosa
was then re-approximated.
Case Report
A 24-year old multiparous woman, with low
educational level presented to the
gynaecology clinic with complaint of
leakage of stool through the vagina for four
years and eight months. Her last child birth
was four months prior to presentation. The
problem started five days after her marriage,
when she realised that she was passing
watery stool through the vagina. Her first
sexual relationship was associated with
serious pain and vaginal bleeding which was
profuse and associated with dizziness. It was
however celebrated by her relatives as a sign
of virginity and was managed with hot
water, herbal medications and high protein
diet. She went to several hospitals without
improvement in her symptoms and decided
to resort to traditional medications. The
problem of faeces leakage persisted
throughout her three deliveries and only
reported to the hospital four months after her
third delivery when they noticed a formed
stool on the husband penile organ.
The vagina was packed with three pieces of
gauze and intra cervical catheter was
inserted. She was continued on intravenous
fluid 1 litre 8 hourly, intravenous antibiotics
and analgesics and was also given a stool
softener, and was subsequently transferred
to the ward
She was reviewed six hours after the surgery
and was found to be fully ambulant. She had
no fresh complaints and her vital signs were
stable. The vaginal pack and intra cervical
catheter were removed. She was changed to
oral medications and continued on low
residue diet, liberal fluid intake and stool
softeners. She continues to open her bowels
normally with no evidence of faecal
incontinence, and discharged on the fifth
day. She was reviewed six weeks later and
with no fresh complaints before finally
discharged from the clinic.
General examination was unremarkable. Her
pulse rate was 80 beats per minute and blood
pressure was 110/70 mmHg. The chest and
abdominal examination were normal. Pelvic
examination revealed normal external
genitalia with widened introitus and
evidence of anterior uterine wall prolapsed.
A rectovaginal examination confirms the
presence of a dimple on the posterior
vaginal wall about 2 cm away from the
perineal body. Speculum examination
confirms the dimples which allow passage
of size 3mm Hager s dilator (Figure 1). The
Discussion
Rectal injuries following intercourse are
quiet rare (Ijaiya et al., 2009; HembahHilekaan and Pam, 2011), unlike coital
injuries affecting the vagina which are more
frequent. The true incidence of coital injury
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Int.J.Curr.Microbiol.App.Sci (2014) 3(12): 845-849
is difficult to ascertain especially because of
non-disclosure of the true nature of the
injury arising from fear of stigmatisation
(Umoru et al., 2003). It was reported to be
0.34% in Maiduguri (Omo-Aghoja et al.,
2009) and 0.7/100 of gynaecological
emergencies in Abkara and Calabar
(Abasiattai et al., 2005; Kriplani et al., 2007).
Dakar, Senegal and USA reported 32 and 30
cases of coital Vaginal injuries per year,
respectively (Michael et al., 2003; Jana et al.,
2008).
Non obstetric vaginal lacerations differ
significantly from lacerations sustained
during childbirth and are generally classified
into two types. The first type is relatively
minor and is associated with normal sexual
intercourse or the first experience of sexual
debut. These lacerations usually resolve with
minimal or no treatment. The second type of
laceration is deeper and more extensive,
often resulting in copious vaginal bleeding.
This condition can be life threatening and
requires immediate intervention (Ahmed et
al., 2006).
emotional and physical preparation of
women for sexual intercourse (Ijaiya et al.,
2009; Hembah-Hilekaan and Pam, 2011).
The transvaginal approach of the repairing
rectovaginal fistulas was used in this case
because the results are generally better.
Rahman et al. (2003) reported 39 patients
undergoing transvaginal repair for low
rectovaginal fistulas with 100% success rate
using this approach (Nisa, 2013). Similar
study reported a success rate of 88% in
patients with no previous repair, 85%
success rate in those with one previous
repair and 55% success rate in those with
two previous repairs (Uzoigwe and Orazulike,
2008).
Bleeding can be profuse, leading to
hemorrhagic shock, and these injuries may
require transfusion of blood products and
surgical repair in some cases. This patient
did not suffer any of these complications.
Other
complications
may
include
hemoperitoneum, pneumoperitoneum and
retroperitoneal hematoma even in the
absence of complete vaginal perforation
(Jeng and Wang, 2007). Coital injury causing
severe vaginal laceration is not uncommon
during first coitus. However, hemorrhagic
shock during consensual sexual intercourse
is quite rare (Eke, 2002). Major risk factors
included
peno-vaginal
disproportion,
excessive force at coitus, urethral coitus,
fellatio and anal intercourse. Urethral
injuries were the commonest complications.
The treatment includes cold compress and
anti-inflammatory agents in contusions,
repairs of lacerations, closure of fistulae and
urethral and vaginal reconstruction. The
results of treatment were essentially good.
Recurrent penile fractures were reported
(Toshiyasu et al., 2011; Yu-Sheng Cheng et al.,
2006).
Various presentations of coital injuries
require careful evaluation, correct diagnosis
and management for a successful outcome
with minimal morbidity (Rahman et al.,
2003). A quick and efficient diagnosis will
require a high index of suspicion by all
attending physicians followed by prompt
and good physical examination including
examination under anaesthesia (EUA) under
adequate lightening (Umoru et al., 2003).
Other sites of coital injuries include right
and left fornices and lower vagina with
occasional involvement of the posterior
vaginal wall. The common predisposing
factors to coital injuries include frenzy
coitus, first sexual intercourse as in this
case, peno-vaginal disproportion seen
premenarchially and after menopause, use of
aphrodisiacs, puerperium and inadequate
847
Int.J.Curr.Microbiol.App.Sci (2014) 3(12): 845-849
Michael, C., Jessica, S., Vivian, P.H. 2003.
Domestic violence and sexual assault.
In: current obstetric and gynaecologic
diagnosis and treatment, 9th edn. Alan,
H.D., Lauren, N.A., (Eds). Lange
Medical Books/ MCGrawHill Medical
Publication Division, USA. Pp. 1087
92.
Nisa, S. 2013. Case series of three postcoital
recto-vaginal fistulae. J. Gynaecol.
Surg.,
29(2):
70 71.
doi:10.1089/gyn.2011.0097.
Omo-Aghoja, L.O., Ovbagbedia, O., FeyiWaboso, P., Okonofua, F.E. 2009.
Coitally related traumatic injury of the
female genital tract in a nigerian urban
setting: A-5 year review. Niger.
Postgrad. Med. J., 16(1): 59 63.
Onsrud, M., Siavelan, S., Luhiriri, R.,
Mukwege, D. 2008. Sexual violence
related fistulas in the democratic
republic of Congo. 103(3): 265 269.
Rahman, M.S., Al-Suleiman, S.A., ElYahia, A.R., Rahman, J. 2003.
Surgical treatment of rectovaginal
fistula of obstetric origin: a review of
15 years' experience in a teaching
hospital. J. Obstet. Gynaecol., 23:
607 610.
Sally, E.P., Matt, Mc Danald, D., Claire, T.
2001. Unrecognised coital laceration
in a series of non virginal adolescents
girls. J. Paediat. Adolesc. Gynecol.,
14(3): 149.
Teresa, H., Jaime, L.B. 2010. Rectovaginal
fistula. J. Clin. Colon Rectal. Surg.,
23(2), PMID: 2967329.
Toshiyasu, A., Toshikazu, O., Yoshie, R.,
Motohiro, S., Tetsuya, L., Katsurou, T.
2011.
Male post-coital gross
hematuria:
are
there
any
complications? J. Men s Health. 8(2):
136 39.
Kriplani, A., Agarwal, N., Garg, P., Sharma,
M. 2007. Transvaginal repair of postcoital rectovaginal fistula in patients of
Conclusion
Rectovaginal fistula is a rare complication of
post coital injury. An early diagnosis
requires a high index of suspicion followed
by prompt and good physical examination
including examination under anaesthesia
(EUA) to exclude the presence of
rectovaginal fistula.
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